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351 19th St PLRS22-0135 Plumbing Permit Application **ALL INFORMATION rS HIGHLIGHTED IN ;i.' City of Atlantic Beach Building Department GRAY IS REQUIRED. . J 800 Seminole Rd, Atlantic Beach, FL 32233 P cRSzz - O ( 35 Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:J.L"Z &'Z JOB ADDRESS: 5,5-7 /G(' ' J • PROJECT VALUE $ 1O0D - EINEW OR REPLACEMENT INSTALLATION and/orE-PIPE TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY Bathtub / Septic Tank & Pit Clothes Washer / Shower _Z._ Dishwasher Shower Pan Drinking Fountain Slop Sink Floor Drain Three Compartment Sink Floor Sink Toilet 2— Hose Bibs Urinal Kitchen Sink / Vacuum Breakers Laundry Tray / Water Connected Appliances Lavatory Water Heater I Other Fixtures Water Treating System ❑MISCELLANEOUS H Sewer Replacement ❑ Back Flow Preventer ❑ Lawn Sprinkler System (number of sprinkler hea•s ❑ Grease Interceptor (Trap) gallons (Requires 3 sets of plans) ❑ Well **SJRWD Well Completion Form.Completed form to be submitted to the Building Department for final inspection.** Other Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have read this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of construction. Owner Name: ZA,CSCS Stie-r_ he c-, Phone Number: 6? %( 522 ;75" Plumbing Company: 57.0c4-0_eeZ ©f A'r fov..d.Cr.,e Office Phone: cfc $o56M 3 7 Fax Co. Address: lcl l ^s ?' L . City: j� sr''-II a State: ci Zip: z Z z.. ----- License License Holder: ss&\ lit( ,s..,-i<c t."`e .7 State Certification/Registration # CfC. (i-I t- •s 3.7 Notarized Signature of License Hold- �i� The fore ing ' strument as acknowledge• before me this z d. , 20 rein the State of Florida, County of '� J OV - •� Signature of Notary Public �.r 1 Personally Known OR [ ] Produced Identification 40 ,.,":;:k,,, T e of Identification: TONI G6'�'DLESPERGER Type . —.! ,: MY COMMISSION#GG 353178 Updated 10/17/18 )1i=;:,'•Eo; EXPIRES:Oct;,ber 6,2023 9 F ` .°Q Bonded T hru Notary Public Underoatters